| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1110 |
Prophylaxis - adult |
6,341 |
6,322 |
$41K |
| D0120 |
Periodic oral evaluation - established patient |
5,328 |
5,313 |
$35K |
| D0330 |
Panoramic radiographic image |
2,810 |
2,803 |
$18K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
2,297 |
2,293 |
$16K |
| D4341 |
|
1,011 |
559 |
$12K |
| D0274 |
Bitewings - four radiographic images |
3,137 |
3,121 |
$8K |
| D1120 |
Prophylaxis - child |
760 |
757 |
$6K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,144 |
2,137 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
4,438 |
4,413 |
$5K |
| D0230 |
Intraoral - periapical each additional radiographic image |
4,453 |
4,190 |
$4K |
| D7140 |
Extraction, erupted tooth or exposed root |
340 |
200 |
$3K |
| D1206 |
Topical application of fluoride varnish |
76 |
76 |
$1K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
40 |
29 |
$738.00 |
| D2391 |
Resin-based composite - one surface, posterior, primary or permanent |
23 |
14 |
$372.00 |
| D2393 |
Resin-based composite - three surfaces, posterior, primary or permanent |
17 |
12 |
$221.00 |
| D0603 |
|
207 |
207 |
$130.00 |
| D0272 |
Bitewings - two radiographic images |
12 |
12 |
$40.00 |
| D1330 |
|
33 |
27 |
$0.00 |